Supporting the Critical Role of Primary Care in the COVID-19 Response

Pandemic response planning has largely been focused on hospitals, personal protective equipment, testing, and contact tracing. But the more we learn about the complex nature of COVID-19 disease, the more it is clear that a successful response also requires a well-funded and robust primary care system. More advanced primary care practice methods will be needed to meet the increasing clinical and social needs of community populations. This is the moment for payers and policymakers to invest in collectively strengthening primary care and community health organizations to create the community-responsive care system needed over the long term.

From day one of the pandemic, COVID-19–related calls have inundated primary care clinics. Care teams mobilized to keep up-to-date with constantly changing clinical recommendations, and helped keep mildly sick patients at home in order to preserve hospital capacity. Clinics also flexed systems to provide coronavirus-safe usual care, including virtual visits, hot lines, and new “respiratory clinics” that were stood up overnight, often in parking lots.

Primary care investment is moving beyond special ad hoc funding arrangements to keep vulnerable practices afloat in the face of decreased revenue due to stay-at-home and distancing precautions. Payers thus have the opportunity to implement COVID- and community-responsive advanced financing mechanisms. These new payment innovation models should incentivize the following:

1. Modernizing primary care access and clinical management
   Basic primary care remains critical to the COVID-19 response, with much of that care now occurring through telehealth. Since infection carries the threat of catastrophic illness, patients need both in-person and virtual access to up-to-date and timely medical guidance to interpret symptoms and make care decisions. Like patients who test positive and are discharged from the hospital or emergency department, individuals who are able to convalesce at home also need continuity of care with close clinical monitoring. Further, the course of COVID-19 disease can be complicated, potentially with longer-term clinical symptoms that require significant chronic disease management. New financing models should not only continue parity for telehealth visit claims but should also prioritize coordination of care and safety net services, incentivize linkages back to public health, and facilitate identification and rapid provider uptake of best clinical practices.
2. Expanding team-based care integrating behavioral health
   The increase in anxiety, depression, substance use, and possibly suicidal ideation from job loss and related insecurities of basic life needs will require increased access to behavioral health and community supports. Over the past decades, primary care practices have been integrating behavioral health providers onto care teams and expanded substance use treatment capacity, despite the limitations of most current funding models. By providing more flexibility through global payments such as capitation, payers can finally incentivize the spread of integrated multidisciplinary primary care even beyond the current pandemic.
3. Conducting screening and follow-up to address clinical, social, and behavioral health needs
   The recommendation to stay at home to avoid viral exposure can create new acute social and behavioral health needs. Primary care has the potential to not only proactively screen and address clinical risks such as lack of medication access and chronic disease instability, but also social risks such as food or housing insecurity and behavioral health risks such as social isolation, anxiety, depression, or substance use. COVID risk stratification tools are being developed based on claims alone or in combination with social and demographic data and implemented to support provider outreach to protect vulnerable and at-risk patients. Here in Oregon, the largest Medicaid Coordinated Care Organization is proactively reaching out to over 50,000 of its members, including those seen in specialty mental health. Given the predicted course of the pandemic, many high-risk individuals may need long-term ongoing support in a variety of clinical, social, and behavioral health domains. What is learned from COVID-19 outreach may also inform the management of chronic conditions generally. For greatest impact, new financing models should coordinate payment to primary care with investment in the community-based organizations that provide targeted services for identified pandemic needs as well as those related to other health conditions. These services can include peer supports, community health workers visits, food and housing access, or services prioritized by the community itself.
4. Building community partnerships and trust
   The effectiveness of pandemic-response efforts is confounded by the underlying tensions in our society, including political polarization, structural racism, and distrust in authority. Half of Americans say they are unsure whether they would get a COVID-19 vaccine if one became available. Success in risk mitigation, contact tracing, and, ultimately, vaccination campaigns will require individual and community trust. Primary care providers appear to enjoy significant trust as individuals, with 84% of patients responding in a recent survey¹ that they were most likely to talk to a primary care provider about potential COVID-19 exposure, almost twice the rate for other contact tracers.As primary care clinics seek to address pandemic-related social needs they are expanding their working relationships with community organizations. Such efforts will need ongoing encouragement and financial support. The investments in COVID-19-responsive primary care will therefore promote community-responsive primary care, helping to build a new foundation of trust critical to all pandemic efforts, including future vaccination initiatives.

Clarity around the crucial role of community-responsive primary care in addressing COVID-19 can promote a more coordinated and effective national pandemic strategy. It can also inform the next generation of overdue primary care financing. Primary care has always lived at the crossroads of physical, behavioral, and community health. Payers have a unique opportunity to strengthen those intersections to improve our nation’s health and reduce health care costs both in response to the current crisis and over the long term.

David Labby, MD, PhD, is health strategy adviser to Health Share of Oregon, the state’s largest Medicaid coordinated care organization (CCO), where he was the founding chief medical officer.

Jennifer DeVoe, MD, DPhil, is a practicing family physician and health services researcher based in Portland, Oregon and the chair of the Oregon Health & Science University (OHSU) Department of Family Medicine.

Andrew Morris-Singer, MD, is a board-certified internist and the founder and chair of Primary Care Progress, as well as co-director of the Morris-Singer Foundation.

Cat Livingston, MD, MPH, is a family physician and preventive medicine physician with expertise in evidence-based policy and an associate professor at Oregon Health & Science University.

Notes

¹Personal email communication of Larry A. Green Center Quick COVID-19 Survey 6/30/2020.